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7835 Main St. Suite 230 Maple Grove, MN 55369

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763-600-6450

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About Vitalign

About Vitalign Spine Clinic

About Dr Chad Herrboldt
Services

What Is NUCCA

Non-Surgical Decompression
Testimonial
Conditions

Spinal Problems

Headaches & Migraine

Neck Pain

Low Back Pain & Sciatica

Injuries/ Disorders

Post-Concussion Syndrome

Whiplash

Vertigo

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Chiropractic for Kids

Chiropractic for Seniors

Chiropractic for Athletes

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Free Online Consultation

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Complete this mini-consultation, and one of our specialists will contact you by mail or email with information pertinent to your health concerns. Please be as truthful and accurate as possible.

Gender*

Male Female

Age Range*

0-10 11-20 21-30 31-40 41-50 51+

Where does it hurt?

Head or Face Neck Shoulders Middle Back Lower back Chest Arm or Elbow Wrist, Hand or Forearm Abdomen Front of Pelvics Hips or Thigh Knees Shins Ankle or Feet

Describe the most painful area*

(Use a 0-10 pain scale...0 being not painful, 10 being excruciating)

When did it start and what makes it better and worse*

If there's a second area of complaint, describe it here*

(Use a 0-10 pain scale)

The reason for treatment is due to a:*

Work related injury Automobile Accident Athletic Injury Progressive (no one injury) Unknown

Describe any condition that may be related to your pain*

(Such as your general health)

Describe treatments you have received and medications that you are taking

Do you have any of the following (If you don't know what it is, do not check the box)

Aortic Aneurysm Spondylolisthesis Moderate to Severe Osteoporosis Pregnancy Lumbar Spinal Fusion or Metal Hadware Spinal or Pelvic Cancer A Recent Low Back Fracture Connective tissue disease like Lupus, Rheumatoid, Arthritis or Scieroderma I DON'T BELIEVE I HAVE ANY OF THESE CONDITIONS

First Name*

Last Name*

Email*

Phone*

How did your hear about us?*

Would you like to schedule a consultation with the doctor?

Yes No Possibly

Be sure to click “SUBMIT” to send all your information. We will respond to you within 24 hours. If you need immediate attention, please call 763-600-6450 and we will do our best to see you the same day.

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call 763-600-6450 TO ARRANGE A CONSULTATION OR COMPLETE THE FORM ON THIS PAGE AND WE WILL CONTACT YOU AT YOUR CONVENIENCE.

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763-600-6450

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Last Name

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Phone

How did you hear about us? *

Would you like to schedule a consultation with the doctor?

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Home
About Vitalign
Services
Testimonial
Conditions
Contact

Home
About Vitalign
Services
Testimonial
Conditions
Contact

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Vitalign Spine Clinic

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Email

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Would you like to schedule a consultation with the doctor?

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